David P. Rapaport, MD, F.A.C.S
905 Fifth Avenue, New York, NY 10021
Phone: (212) 249-9955 Fax: (212) 249-0439
SPOUSE OR PARTNER CONTACT INFORMATION [If applicable]
EMERGENCY CONTACT INFORMATION:
Height: feet* feet inches* inches
Weight: feet* lbs
PERSONAL MEDICAL HISTORY:
Assignment & Release
I First Name* Last Name* assign directly to Dr. David P. Rapaport and associates all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges incurred. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
David P. Rapaport, M.D., & associates feels strongly about his patients' privacy as well as his practices' right to control its public image and privacy. David Rapaport, M.D., and associates agrees not to be paid for selling patients lists or protected health information to any third party for the purpose of marketing directly to his patients. In consideration for treatment and the above noted Patient protection, Patient agrees to refrain from directly or indirectly publishing or airing commentary upon the Physician; and they will use all reasonable efforts to prevent any member of their family from engaging in such activity. David Rapaport, M.D., and associates has the right to equitable relief to prevent the initiation or continuation of publishing or airing of commentary upon his practice, expertise and/or treatment. Both Physician and Patient will work to prevent the publishing or airing of commentary about the other party from being accessed via internet, blogs or other electronic, print or broadcast media without prior written consent. Finally, this Agreement shall be in force and enforceable for a period of five years from Physician's last date of service to Patient. Patient has been given the opportunity to ask questions and receive adequate answers to his/her satisfaction. Refund policy: Please note that our office does not provide refunds on any services rendered. All sales, including deposits for treatments, are final. Skincare products may be exchanged if damaged or unused within 14 days of purchase.
Scheduling Agreement, Credit Card Authorization & Treatment Deposit Form
Life happens! We understand that a situation may arise that could force you to cancel or postpone your appointment. We would like to kindly remind you of office policies & procedures regarding the cancellation, no show, scheduling and/or rescheduling of all appointments. Please note this includes complimentary appointments.
A valid credit card is required at the time of scheduling your appointment. Consultations with Dr. David P. Rapaport are $500.00, due 48 hours prior to the scheduled appointment. The consultation fee is non-refundable. Your consultation fee of $500.00 is applicable to your surgical quote for up to one year from the date that you were given your surgical quote.
Consultations with Coolspa are complimentary. If you are unable to keep your appointment 48 hours’ notice is required. We reserve the right to charge a $50.00 penalty fee for consultation appointments that are missed or cancelled with less than 48 hours’ notice. I understand that Coolspa has a “48-hour Cancellation Policy” which holds me responsible to cancel 48 hours in advance of my scheduled appointment time. In failure to do so will result in a charge to my credit card of $50.00.
Dr. Mansher Singh offers complimentary consultations for cosmetic procedures; however, please note that a valid credit card is required to schedule your appointment. If you cannot keep your appointment, the courtesy of at least 48 hours’ notice is requested. Please contact our office at least 48 hours prior to your scheduled appointment to avoid the no show/cancellation fee of $100.00.
As you can appreciate, there is a tremendous amount of work performed by Coolspa, David P. Rapaport, M.D., F.A.C.S., and any of its Associates/Providers in both front and back office to schedule your appointment. Please therefore be advised that it is the policy of the office to charge a non-refundable scheduling deposit when a patient chooses to secure a treatment day. The scheduling deposit is non-refundable.
Time allocated for an appointment is reserved especially for you. We do understand that sometimes schedule adjustments are necessary; therefore, we require at least 48 hours’ notice and/or 2 business days for cancellations or to make changes to your appointment. This is because that appointment time has been held specifically for you, while others have been turned away. Business days include Mondays through Fridays. Monday and Saturday appointments must be cancelled by Thursday.
If you arrive more than 15 minutes late to your appointment, we cannot guarantee that you will be seen by the provider. Unfortunately, this pushes back the entire schedule, and it is unfair for the patients who are after you.
All reservations for office procedures require a credit card on file and/or deposit. Deposits and payments for procedures are non-refundable. Initials: please initial*
The procedure/treatment date & time may be changed as the schedule allows, with a minimum of 48 hours advance notice and/or 2 business days. Because of the length of time needed to schedule your treatment, changes to all appointments with less than 48 hours’ notice or “no shows” will incur a penalty fee and/or forfeit your deposit. To cancel a Monday appointment, please call our office by 5:00 PM EST on Friday. Initials: Please Initial*